California is overhauling its substance abuse treatment system for low-income people, embarking on a massive experiment to create a smoother path for addicts from detox through recovery.

‘This was a long time coming. It’s a win/win for people with substance use issues and their families.’Keith Lewis, executive director of Horizon Services

The state is the first to receive federal permission to revamp drug and alcohol treatment for beneficiaries of Medicaid, known as Medi-Cal in California. Through what’s known as a drug waiver, state officials will have new spending flexibility as they try to improve outcomes and reduce social and financial costs of people with substance abuse disorders.

Under the waiver, the state plans to expand treatment services, including inpatient care, case management, recovery services and added medication. Beginning next year, drug treatment centers will be able to get reimbursed for providing this much wider range of options to people on Medi-Cal.

Only a small fraction of low-income Californians with substance abuse disorders receive treatment, largely because of restrictions on what Medicaid will pay for.

“This was a long time coming,” said Keith Lewis, executive director of Horizon Services, which provides treatment in San Mateo, Santa Clara and Alameda counties. “It’s a win/win for people with substance use issues and their families … and for the people providing those services.”

The changes will be phased in next year, beginning first in Bay Area counties before going to Los Angeles and Orange counties.

The changes stem in part from the Affordable Care Act, which required that substance abuse treatment be covered for people newly insured through Medicaid or insurance exchanges. The health law allowed states to expand Medicaid to cover millions more people.

Drug rehabilitation providers say the changes will give addicts a better chance at getting — and staying — clean. But they fear the state won’t raise traditionally low Medi-Cal reimbursement rates for treatment, making it harder to provide the new services and produce the outcomes California is hoping for.

Lewis, of Horizon Services, said that under the waiver, he expects drug treatment services to be higher quality and the workforce better trained. But he said that “Medi-Cal rates, which have always been too low, have to go up.”

California’s Medi-Cal drug treatment program currently costs about $180 million annually, paid through a combination of state and federal funds. There aren’t any estimates for costs under the new approach, set to begin next year. But the idea is that the changes will lower overall health care expenses by enabling more people to get sober and healthier so they stop rotating through treatment centers, jails and hospitals.

New Access to Residential Treatment

Nearly 14 percent of Medicaid recipients are believed to have a substance abuse disorder, according to the National Survey on Drug Use and Health.

The five-year pilot project was approved by the federal Centers for Medicare & Medicaid Services in August. Under the waiver, California counties will approve treatment for Medi-Cal patients based on medical necessity and criteria established by the American Society of Addiction Medicine.

Currently, federal rules limit drug treatment centers’ ability to get reimbursed under Medicaid for residential care. Clinics with more than 16 beds essentially cannot get paid, except for treating pregnant and post-partum women. That restriction will be dropped for California under the waiver.

Now, Medi-Cal beneficiaries will be able to access up to two 90-day residential stays each year (with a possibility of one 30-day extension) if providers determine that it is medically necessary. Certain populations, including those in the criminal justice system, can get approval for longer stays.

John Connolly, deputy director of substance abuse prevention and control for the Los Angeles County Department of Public Health, said the waiver is also designed to provide better coordination between physical, mental health and substance abuse services. That, along with more access, could result in fewer emergency room visits and hospitalizations, he said.

Treating Substance Abuse as Disease, Not Short-Term Illness

That’s potentially good news for patients like Caitlin Knoles, who says she gets turned down for treatment of her methamphetamine addiction every time she tells residential centers she’s on Medi-Cal. More than once, she has ended up in the hospital because of her addiction.

“It’s hard,” she said. “I can’t get help.”

The only way she can reliably get clean now is in jail, she says.

“It’d be nice to have a job and have my family back and just be normal,” said Knoles, 24, as she sat outside a liquor store in Laguna Hills.

For the first time, substance abuse disorders will be treated like a disease rather than a short-term illness, said Marlies Perez, chief of the substance use disorder compliance division for the state Department of Health Care Services.

“Even though we know it’s a chronic condition, we have treated it acutely,” she said. “If they relapse, they have come right through the front door again.”

“We are really paving the way in California with this waiver,” she added.

Much depends, however, on reimbursement rates, which are still being negotiated. Clinic officials say they need higher rates to expand services and handle the influx of clients, many of whom will be seeking rehab for the first time.

Los Angeles County-based Tarzana Treatment Centers provides both outpatient and inpatient care for children and adults with substance use disorders and mental illnesses. (Anna Gorman/KHN)

“There is a cost to raising the bar on treatment,” said Albert Senella, president of the California Association of Alcohol and Drug Program Executives. “If the rates aren’t adequate … we are not going to be able to effectively meet the [new requirements] and the needs of the population.”

Senella, who is also CEO of Tarzana Treatment Centers, said many clinics across the state don’t have money upfront to prepare for the overhaul, which will require improving technology and adding and training staff. For now, no plans are in place to provide counties or clinics with startup funds.

But in addition to fears about rates, Veitzer said he is also worried that 90 days — the limit for residential treatment — won’t be long enough. Someone may be able to stem their addiction in three months but will still need more time in a treatment facility to prepare for life outside.

“If their ability to function independently in the community is not addressed, they are likely to relapse,” he said.

Danny Montgomery, a 33-year-old patient at Tarzana Treatment Centers, said he needed more than a few months to get clean after nearly a decade on heroin. The addiction, which he estimated cost him up to $100 a day, caused him to lose his job and nearly lose his family.

“The whole thing is a process,” said Montgomery, who lives in the San Fernando Valley. “You get the substance removed from your body but you have to retrain your mind.” Montgomery said he tried to get a bed in a residential treatment center but couldn’t find one that would take Medi-Cal.

He tried to get clean on his own but it never lasted. Months after beginning his search, Montgomery was finally able to get a spot at Tarzana. He said Los Angeles County is paying for his stay, which began in May.

As worried as they are about reimbursements, clinic operators said a big advantage of the new approach to drug treatment is that it could help stabilize their funding. Providers now depend largely on counties to pay for residential treatment for low-income residents.

“You always suffered the vagaries of the budget cycle,” said Vitka Eisen, CEO of HealthRIGHT 360, which provides drug treatment in the Bay Area.

The waiver means increased oversight of treatment centers. Last year, a state audit found widespread fraud and questionable billing among Medi-Cal drug treatment providers. The audit followed reports by the Center for Investigative Reporting that clinics were billing for fake clients.

Perez, of the state Department of Health Care Services, said the new system builds in more levels of accountability, including more stringent requirements for clinics and more local control over contracting.

Knoles, the methamphetamine addict from Orange County, said she hopes that more people like her will be able to get treatment.

“I’ve had a lot of friends die from addiction,” she said. “Imagine if they’d gotten the help they wanted and needed. Things would have been different.”

I agree that this is way, way overdue. But the devil will be in the details. Longer residential treatment is good because alcoholism and heroin/meth addictions require a lot of structure, support, and treatment if they are to be overcome. Very active, ongoing follow up via case management (sometimes daily) and coordination with medical and psychological services will be essential. It takes years to develop an addiction. It can take years to overcome it.

I hope the counties overseeing these service expansions will move slowly. Lots of staff training and ongoing supervision will be needed. It is far better to do it more slowly and to get it right than to rush in and do it sloppily. Watch out for fraudulent billing practices! These are all too common in such programs because they are poorly funded and understaffed.

Alan Wartenberg

The best evidence is that drug-free treatment, no matter how intense or of whatever duration, works well for at most 15% of the abusing population, with most studies in the 5-10% range. Some period of medication-assisted treatment with buprenorphine or methadone, generally at least 2 years, combined with effective psychotherapy/medication for underlying trauma issues (almost invariably present) as well as lifestyle modification and complementary therapies (meditation, yoga, acupuncture etc) may increase the percentage of patients who can maintain a drug-free treatment. It is likely, however, that a large percentage will require medication-assisted treatment indefinitely. I see this nowhere in this plan. Residential programs are extraordinarily expensive, considering the bang for the buck, and medication-assisted treatment is extraordinarily cheap, considering IT’S bang for the buck. It is likely that use of extended-release naltrexone may improve the ability of larger number of patients to achieve drug-free sobriety, but the long-term efficacy and safety is not yet known.

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California faces health care challenges seen across the country. At a time of intense focus on reform, "State of Health" explores these issues and more, bringing you stories of challenge and change in the Golden State. The blog is edited by Lisa Aliferis.